The NHS has been in the news a lot recently – mostly due to it being in “crisis”(1), but another headline has hit the news recently. Permission has been granted for a group of campaigners, supported by Professor Hawking, to take the government to the High Court to challenge changes to the NHS – the formation of Accountable Care Organisations(2).
How does the NHS work?
The NHS is a huge organisation. It has by no means a simple structure. Here I will attempt to summarise the way the NHS works(3).
The NHS is funded by the Government. Most of this money is given by the Government to NHS England. This is (another) large organisation which commissions NHS services. This means that they are responsible for services needed by the NHS being arranged and paid for.
Most of this commissioning is done by CCG’s – these are Clinical Commissioning Groups. These CCG’s are made up of healthcare staff, including doctors and nurses, and also other staff including advisers. CCG’s are designed to commission services for a local population to better provide for local needs and concerns. The services it can arrange include those from hospitals or Trusts as well as private providers and charitable groups.
Lots of other organisations are involved in running the NHS – including NHS Improvement and Care Quality Commission (CQC), among many others.
What are the Changes?
NHS England has produced a “5 Year Forward View“, this sets out some of the proposed changes(4). There is a consensus that the way the NHS is currently run – with separate hospitals, GP Practices, Community services all working individually – is not sustainable given the increasing demands on the NHS.
Sustainable & Transformation Partnerships (STP’s) are a way of providing “place-based plans”(5). They bring together the individual parts of the NHS to help them work together for a set population. These individual parts include GPs, hospitals, mental health and social services. The integration of these services, to help provide more specific care, is planned to take a more formal form in Accountable Care Systems (ACS’s) and Accountable Care Organisations (ACO’s)(6). The term first arrived in the USA, where it formed a basis of President Obama’s healthcare reforms to provide better healthcare and try to cut costs.
These all sound like the same thing, but there are subtle differences. ACS’s are an evolution of STP’s, bringing together some NHS providers and local authorities to work as partners. ACO’s are a formalisation of the above – NHS providers are merged, creating a single organisation or contracting a private company to deliver these services.
What’s the Problem?
Integrating care and making services work together for better healthcare sounds like a good thing. Anything to improve the care the NHS can deliver to patients and deliver this more efficiently should be supported, surely?
But several people have raised objections to the implementation of ACO’s(7). The main issue is accountability. Even though it’s in the name, it’s unclear who an ACO will be accountable to. They can be made up of numerous combinations of organisations, NHS or not, and even privately run.
In essence, there is a fear that an ACO could end up being privately run, including institutions like insurance companies and banks, have numerous contracts with different providers – charities, GPs, Trusts – and have a lack of regulation from Government. This concern, combined with these contracts possibly being worth billions of pounds is concerning. Also, whether an ACO would have a contract under commercial law or be accountable to the Government or Department of Health (DoH) is unclear (7).
As a result, a campaign group has been established by several doctors and professors, and has received the support of renowned physicist Professor Stephen Hawking. This group has recently won a judicial review to further explore, and find answers to, the concerns mentioned above, among others.
The fact that this has been granted, and that the DoH has announced a period of consultation means that the concerns regarding ACO’s aren’t necessarily a minority view.
How this consultation period and judicial review pan out will be very interesting indeed for the future of the NHS.